Workers’ Compensation

It is the policy of the State to have an employee notify his or her supervisor of an occupational injury and/or disease within 24 hours of the injury or illness. The employee must report the injury to his or her supervisor or other designated authority without delay regardless of the seriousness of the injury or its cause. Any delay in reporting your injury increases the chance that it may be disputed. An accident report form for personal injury on campus should be filled out by the injured party and forwarded to his or her immediate supervisor and the Human Resources Office as soon as possible. You must see someone in the provider directory in order to put your claim through workers’ compensation.

Workers’ Compensation Process

All three categories of reported claims require the use of the DAS Workers’ Compensation Claim Reporting Packet.

Report Only: An incident that is reported by an employee to the supervisor, but no medical attention is being sought. (Who completes this?)

Medical Only: An incident that is reported by an employee to the supervisor with corresponding medical treatment, but the injured employee loses no time from work. (Who completes this?)

Lost Time: An incident that is reported by an employee to the supervisor with corresponding medical treatment, and the injured worker loses time from work. Supervisor Completes this form.

DAS WC Claim Packet

DAS Form 207 – First Report of Injury: This form is used to record information when phoning in the claim to the TPA Injury Intake Center and reviewing the claim in CORE-CT by the human resources (HR) claim-processing unit. The supervisor must provide accurate information on the completed form and to the intake specialist, as it is the basis for the establishment of the claim in CORE-CT. (Completed by HR with information from Supervisor.) Call 1-800-828-2717 – CCC79300 (location code)

DAS Form 207-1 – Incident Review Report: This form is completed by the supervisor to record information used for loss control purposes. Form 207-1 identifies the root causes of injury to establish corrective action to reduce the potential for future injury. This form is available in many formats. Work with DAS Workers’ Compensation to design a specific form to meet your agency needs.

WCC Form 1A – Filing Status and Exemption: This Workers’ Compensation Commission form is used to record the injured workers’ federal income tax filing status and number of exemptions for use in establishing the base Workers’ Compensation rate. HR completes the form.

DAS Form PER-WC 211– Concurrent Employment and Third Party Liability: Completed only if the injured worker has any employment other than the State of Connecticut for potential concurrent employment benefits and to identify any third party negligence-giving rise to the injury.

DAS Form WC-715 – Request for Use of Accrued Leave With Workers’ Compensation: This form is used to designate the injured worker’s election to utilize or not utilize accrued leave during the interim period and/or to supplement lost wage workers’ compensation benefits on an approved workers’ compensation claim. Note: General Letter 78 provides agencies with guidance regarding the optional use of accrued leave with workers’ compensation claims. The accrual of sick and vacation leave credits while receiving workers’ compensation is governed by C.G.S. 5-251 and is further explained in the DAS Workers’ Compensation manual.

DAS Form 208– Worker Status Report: This form is completed by the initial care or attending physician to record the injured workers diagnosis, course of treatment and work disposition.

Supervisors/HR responsibilities for recording and facilitating an employee’s claim for WC benefits

Obtain emergency medical care if needed

Complete claim packet

Phone claim into TPA injury intake center / 1-800-828-2717

Forward completed claim packet to agency WC office

Take corrective action to remove exposure(s) that caused the injury

Prompt and accurate completion of the WC Claim Packet enables (a) the injured employee to pursue his/her claim and (b) the agency and TPA to obtain critical information associated with the reported claim.